eTicket

Example of another type of data that can be collected.

1. Please indicate your service unit

ESU 1
ESU 8

2. By what means did you deliver your service to the district(s)?

Phone Conference Call
Skype/iChat
Webinar
PolyCom/DL
Onsite Service
At ESU
Email
Other?

3. If you participated in the service delivery or meeting via technology, how many miles did you save? (Enter just a number. i.e. 45)

4. Please indicate the number of people served. (Enter just a number i.e. 10)

5. Please indicate the date on which you provided the service.

MM-DD-YYYY

Date of service:	Please indicate the date on which you provided the service. Date of service: Month	/	Day	/	Year

6. Please indicate the amount of time spent in providing the service.

Days Hours Time Spent

1. Please indicate the district(s) you provided service to

Allen Bloomfield Coleridge Creighton Crofton Emerson-Hubbard Hartington Homer Laurel-Concord

Newcastle Niobrara Pender Ponca/Jackson Randolph Santee South Sioux City Umo Ho Nation Verdigre

Wakefield Walthill Wausa Wayne Winnebago Winside Wynot ESU 1 & 8 Collaboration

2. If your site isn't in the list above, please specify the location in this box.

1. Please identify your department(s)

Staff Development
PT/OT
Technology
Early Childhood
Psychology
Speech/Language
Transition
Visual/Hearing Impaired
Special Ed
Administration
ESU Administration
Media
Nursing

2. Collaborative Planning?

Yes
No